Gestational Carrier Application Form

    Basic Information

    • NAME
    • *EMAIL
    • *PHONE NUMBER
    • Date of Birth
    • WEIGHT
    • HEIGHT
    • How many children do you have?
    • Where do you live? (Only state and city)
    • Are you a US citizen?
    • What is your race?
    • Marital status?
    • What languages do you speak?
    • Do you have reliable transportation?
    • Do you have a valid driver license?
    • Do you have health insurance? Please name the carrier.

    Education/Employment Information

    • What is the highest-level education you have completed?
    • Do you have plans on furthering your education?
    • Are you currently employed?
    • Who is your present employer?
    • Please describe your occupation/job title
    • Are you full time or part time?
    • Are they flexible with you taking time off for appointments?
    • Do you think if you can commit yourself to thesurrogacyprocess, given your current schedule and responsibilities?

    Pregnancy Information

    Delivery date
    Mm/dd/year     		Weeks Babies delivered Vaginal / C-Section Gender Weight Own / Surrogacy Complications
    1
    2
    3
    4
    5
    • Have you ever had an abortion?
    • Have you ever experienced the following conditions? Please explain if any
    • Gestational Diabetes
    • Hypertension
    • Toxemia
    • Placenta Previa
    • Pre-Eclampsia
    • Placenta Abruption
    • Post-partum depression
    • Pre-term labor
    • Short cervix
    • Bedrest
    • Are you currently breastfeeding?
    • Are you sexually active?
    • Are you using birth control?
    • Do you have regular monthly menstrual cycles?
    • What is the date of your last menstrual cycle?
    • When did you last see your Ob/Gyn?
    • What is the date of your last Pap Smear? What is the result?
    • Please list any reproductive illness you have ever experienced.
    • Do you want any additional children of your own? (if answer isyes, let them know that surrogacy could possibly affect theirfertility in the future)

    Medical Information

    • Your Blood type?
    • What is your Rh factor?
    • Do you drink alcoholic beverages?
    • Do you or anyone in your household smoke?
    • Do you or anyone in your household use illicit drugs?
    • Have you had any form of Tobacco, Marijuana, or any form of illicit drugs within past 6 months?
    • Are you taking any medication?
    • Are you currently being treated for any medical conditions?
    • Please list any significant illness you have had.
    • Please list any hospitalization or operations you have had.
    • Have you ever taken medications for depression or anxiety?
    • Have you or any of your partners ever been hospitalized for psychiatric illness?
    • Have you been immunized for HepatitisB in the past?
    • Have you ever been diagnosed with the following diseases? Herpes; Gonorrhea; Chlamydia; Syphilis; HPV; Genital warts
    • Has your partner/spouse ever been diagnosed with herpes, gonorrhea, chlamydia, syphilis, HPV or genital warts?
    • Are you currently using any form on contraception? If so, what type and how long?

    Family Support

    • Do you have a spouse or significant other?
    • Does your family support your decision to become a Gestational Carrier?
    • Who would help if you were ordered to be on bed rest for a period of time?
    • Do you anticipate any difficulties in becoming a surrogate?
    • Describe you current living conditions
    • Please list everyone living in your household including ages and relationship.
    • Do you have any pets at home?

    Decisions

    • Are you willing to work with intended parents who are hetero-sexual couples (male/female)
    • Are you willing to work with intended parents who are hetero-sexual individuals
    • Are you willing to work with intended parents who are same-sex couples (male/male or female/female)
    • Are you willing to work with intended parents who are same-sex individuals
    • Are you willing to carry twins?
    • Are you willing to carry triplets?
    • If you become pregnant with multiples, would you be okay with a reduction for one or any of the following reasons?
    • Are you willing to carry for an IP/s who carries Hep B Virus?
    • Are you willing to carry for an IP/s who does not carry Hep B virus, but recovered from an old infection (Not infected)?
    • Are you willing to carry for an IP/s who have HIV?
    • Are you willing to carry a child whereby the recipients used donor eggs or donor sperm?
    • If the IPs request terminating the pregnancy, would you agree to one or any of the following:
    • Would there be any reason you would not be willing to terminate? Or for a specific reason? (i.e., cleft lip, missing limb, gender)
    • What kind of relationship do you want with the intended parents during conceptions and pregnancy?
    • Are you willing to allow fetal surgery based on a doctor's recommendation to help the child in utero?
    • Are you willing to do somewhat invasive procedures during your surrogacy if medically necessary? For example, D&C, Amniocentesis and /or Chronic Villus Sampling.
    • Are you willing to pump breast milk after birth?
    • You will be required to take IVF medications. Some meds might require using injectable needles. Do you agree to take ALL medications required?

    Characteristics

    • What do you like to do in your spare time?
    • Please use five words that best describe your personality:
    • What is your favorite part about being a mom?
    • How do you see your ideal surrogacy journey? Why do you want to be a surrogate?
    • What message would you like to give to your Intended Parents?
    • What are your hobbies, interests and talents?
    • What is your favorite food?
    • What does your daily diet consist of?
    • Additional photos please upload a few photos to show you, and / or you with your families/friends.

    • Our team will contact you later